Our findings support prior literature implicating Th17.1 cells in the pathogenesis of sarcoidosis. However, we demonstrate these findings in patients with melanoma prior to administration of checkpoint therapy and before the onset of clinically symptomatic sarcoidosis. The identification of elevated Th17.1 cells in melanoma patients who have not developed sarcoidosis may reflect the established association between melanoma and sarcoidosis. With some patients receiving these agents over a prolonged period, the clinical course of immunotherapy-induced sarcoidosis is uncertain.
Many clinicians are unaware of these events, which may come to have wide-ranging detrimental effects. One possible cause is the lack of training of junior medical staff in obtaining consent for postmortem examination, though other factors are also important. KEY WORDS: audit, autopsy, decline, diagnostic errors, post-mortem examination IntroductionPost-mortem examinations (PMs) have been important in the development of modern medicine, their value having been recognised for about two centuries. 1 PMs of hospital patients should continue to be valuable in clinical governance by providing an independent means of checking the accuracy and completeness of ante-mortem diagnoses and an assessment of the effects of treatment. Indeed, a programme of well-conducted clinical PMs forms the heart of a method of quality assessment of medical diagnostics. 2 Additional benefits include: a greater understanding of disease and its management; the description of new diseases or the effects of new treatments; 3 the retention of tissue and organs for teaching and research; the training of medical students, 4 junior doctors and histopathologists; 3 and continuing professional development of clinical consultants. They also increase awareness of the multiplicity of conditions which many patients (particularly the elderly) have and of the level of uncertainty -'necessary fallibility' -in medical practice. [4][5][6] Moreover, the greater understanding following PM may also be beneficial for the family, 7 something that should not be overlooked when the recently bereaved are counselled by clinicians. This is particularly the case in pregnancy loss and possible inheritable disease, where there may be important implications for other family members.It has long been recognised that the clinical (consented) PM is in decline 1,5,[8][9][10][11][12] and, if not dead, then terminally ill. 13 In Britain, this decline appeared to start in the 1950s 8,12,14 and has continued ever since. There are, however, few recent data to support this contention, and the effects of the publicity following events in Bristol and Liverpool have not been explored. Here we describe the recent consented PM rate for patients dying in the Norfolk and Norwich University Hospital NHS Trust (NNUH), which has 989 beds and serves a population of at least half a million, and the nature of the consent given. We also explore clinicians' opinions about the numbers of PMs they request and how they obtain the necessary consent. Methods Review of the numbers and extent of consented post-mortem examinationsWe examined the records of the mortuary and Department of Histopathology for the period 1 January 1996 to 31 December 2003 to determine the number of adults dying in NNUH, the number undergoing consented PM, and the extent of the examination permitted by that consent. From these data we derived the clinical PM rate (number of consented PMs divided by the number of deaths, expressed as a percentage). The number of stillbirths and perinatal deaths, the number of consented PMs undert...
The adult clinical necropsy has been declining for many years and is nearing extinction in many hospitals. In Norwich, to prevent this from occurring, a Pathology Liaison Nurse (PLN) was appointed, resulting in a modest reversal of the trend. In 2005, the number of adult clinical necropsies increased to 58 (clinical necropsy rate = 2.4%) from its nadir of 34 (clinical necropsy rate = 1.4%) in 2003. Moreover, consent is now much more likely to be full and to allow histopathological and other studies. The PLN ensures that consent is properly and fully obtained, in line with current legislation. She also plays an important role in arranging for feedback to be given by clinicians to the families after the examination, and in teaching and training Trust staff about death, bereavement, and related matters. This paper describes how the role of PLN was established and evaluated, and gives details of the current state of the adult clinical necropsy in Norwich.
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